Who needs a Form MA 6(A)?
All persons, who use medical services. The following form may be filed by individual or nurse.
What is for Form MA 6(A)?
MA 6(A) form is a physician’ recommendations for pediatric care. All items inside this form are important
for mentioning. “N/A” variation of answer is not allowed in filing this form. You must remember this rule
and inform nurse, who may help to file this form, that all fields are important for filling.
Is MA 6(A) accompanied by other forms?
Form MA 6(A) is not accompanied by other forms. But it has to be supported by medical documents.
When is MA 6(A) due?
This form valid only 90 days after date of filing.
How do I feel out Form MA 6(A)?
You and medical staff must note the following information (don’t forge—?? — all information is important for
noting!):
- Applicant’s name and address.
- Medicaid Number
- Social Security number
- Age, Sex and Birthdate
- Primary care physician
- Phone number of applicant
- Note the need in being institutionalized
- Does the child attend the school (mark common checkbox)
- Date of Medicaid Application (must be noted by staff)
- Data about caregiver to applicant
- Signature
- Date (must be noted by applicant)
- History must be attached. Or just described if sheet is absent
- Diagnosis must be attached
- Medications used
- Procedures for treatment and diagnosis
- Plan of treatment
That’s the main fields, which must be used. For noting other fields, ask medical staff for help. All fields may
be filled by medical staff, applicant or legal representative only.
Where do I send Form MA 6(A)?
Form must be sent to the head of hospital or specific department in hospital.
